Healthcare Provider Details

I. General information

NPI: 1750861613
Provider Name (Legal Business Name): KATHLEEN TABB RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7219 HANOVER PKWY STE D
GREENBELT MD
20770-2021
US

IV. Provider business mailing address

7219 HANOVER PKWY STE D
GREENBELT MD
20770-2021
US

V. Phone/Fax

Practice location:
  • Phone: 301-474-2499
  • Fax:
Mailing address:
  • Phone: 301-474-2499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDX4495
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: